Thursday, March 26, 2015

We regularly have patients who give us immense satisfaction
at places like Kachhwa. Mrs. PPD was such a patient.

Mrs. PPD came to us in a very serious shape – more serious
emotionally than physically. Just 33 years of age, PPD had been diagnosed to
have Diabetes Mellitus about 6 years back. She had been running from one doctor
to the next since then. She was scared of Insulin shots. Almost all the doctors
she met told her the truth - the fact that she needed Insulin to keep her
diabetes under control. But PPD was scared.

The depressive nature of PPD brought a sense of doom to her
extended household. Her mother-in-law narrated on how the illness seems to have
brought a pall of gloom into the home.

PPD came to us about a month back with serious infection.
She was depressed and wanted to die. It was a major struggle for us to convince
her that she needed insulin injections. Our team did quite a bit of persuasion
and prayers to convince her. Initially, she was not ready to self administer
the medication.

Over the course of her admission, we discovered that she had
bilateral cataract. The issue was about getting the surgery done while the
‘surgery season’ was on. And then there was the spectre of diabetic retinopathy
which could dampen the surgery. Of course, someone had went to the extent of
telling her that she will not see again that she did not bother to mention
about her low vision to us. It was one of our staff who noticed that she was
fumbling with things that we realised that her vision was as low as 1/60.

We prayed for her. By God’s grace, from a situation of
seriously uncontrolled sugars, the sugar levels were well controlled and she
was able to undergo surgery.

Post-surgery, we were all concerned about how much vision
she would be able to have. On removing her bandages, we praised God as she told
us about how clearer her world has become.

PPD (left with the dark glasses) with her mother in law
(Consent obtained for posting snap)

PPD’s mother narrated on how she has become a lively
presence in the house after her treatment. It’s so satisfying to have patients
like PPD who appears to have lost all hope for her future. However, we're sure that had it not been for her extended family who was ready to stand with her in the treatment and encourage
her, they would not have been able to bring back hope and joy in the house.

About a week back, we had a young lady of 16 years brought
to Emergency Room in a supposedly comatose state after a snake had coiled
around her leg. The patient alone had seen the snake and had told relatives
before she became unconscious that the snake did not bite her.

There were no obvious bite marks and it was not difficult to
come to a conclusion that she was well conscious although appearing a bit
drowsy. She also seemed to have a ptosis which on careful examination was not
there. The clotting time was normal.

The only issue was a low blood pressure reading of 80/40 mm
Hg. We gave her some intravenous fluids and she did not respond to that. And we
concluded that this was her normal blood pressure. Later, we found out that
there were problems in her family and we diagnosed her as having an acute
conversion reaction – a psychological response to difficult situations.

We gave her a small dose of anti-depressant. However, she
did not seem to do fine. She continued to remain drowsy. She could communicate
when we called her. She could even walk to the toilet without help. She also
narrated to us that she was taking some ayurvedic drugs for her psychological
condition.

The next day being a Sunday, we could do any investigations.
Her condition remained the same.

On Monday, we sent a battery of tests – complete blood
count, liver function and renal function.

Her total count came as 1200/cu mm with a predominant
lymphocyte picture. Hemoglobin and platelets were normal. The liver and renal
function also came as normal.

There were only two major things that we were looking at – either
a blood dysgracia most probably secondary to her ayurvedic medications or a
haematological malignancy.

We referred her to a higher centre.

This is the second time that I’ve come across a
suspected snake bite being diagnosed with something else more serious. The
previous time was 4 years back at NJH, when we diagnosed disseminated
tuberculosis in a patient who came with an unknown bite.

Yesterday, I had a patient who sort of broke all records for the number of medicines that he was taking. I counted a total of 21 medications. He has been having fever, cough and breathlessness since the last 2 weeks.

This is Sergeant
Kuruvilla, reporting from the battlefield in the war against Tuberculosis.

Thank you for your
greetings on World Tuberculosis Day. It’s been more than a century since we’ve
sighted the enemy, but alas there seems to be no end to the hoards of their
armed regiments.

At the front,
Lieutenants Rifampicin and Isoniazid continue to do a commendable job inspite
of the fact that the enemy has designed specific weapons against them called
Drug Resistance. Lieutenants Pyrazinamide and Ethambutol continue to serve
well, although there are reports of our own troops being injured by them
unknowingly during combat.

However, I need to
point out issues which our own troops have been guilty of. Quite a few of our
troops do not heed to the leadership of Isoniazid, Rifampicin, Pyrazinamide and
Ethambutol after some period of time. Instead, they put themselves susceptible
to the machinations of the enemy tubercle bacilli. It is quite sad to see this
happen.

I’m encouraged
that there is evidence that if standard epidemic control measures are put inplace, we would achieve control on the spread of the disease. We need to follow the basics of public health care. The eight essential
components of ‘Primary Health Care’, outlined at the Alma Ata declaration give
us enough guidelines to stifle the enemy.

With poor primary
healthcare and emphasis on setting up tertiary care institutes all around the
battle fronts, this objective is not going to be met. Priorities on tackling
malnutrition, rural to urban migrations and overcrowding have to be given
priority.

Considering this
year’s slogan, I’m sure that there need to be some major changes in our approach to
treat tuberculosis. Reaching each of our patients would be a reality only if we
allow active detection of cases. The World Health Organisation charter for
treatment for tuberculosis has already accepted the superiority of daily drug
therapy to intermittent therapy. In India, we need to slowly shift to daily
treatment. There is presently no mechanism to ensure that patients remain cured
after the completion of treatment. Relapse and re-infection remain hugely unaccounted
for.

Saturday, March 21, 2015

About a week back,
we had a 65 year old man come to outpatient with a history of breathlessness
since the last 6 months which increased over the last 2 days. He was so
breathless that he could not lie down and it was obvious that he had not had a
good sleep since some time. He had a saturation of about 10% which increased to
85% with 5 litres of oxygen.

He was quite
confused and made quite a scene on the first day of admission.

On examination, he
had bilateral fine crepitations in his chest with a decreased air entry on the right side and
other features suggestive of a right sides pleural effusion. On Chest X-Ray, he had right
sided pleural effusion and later ultrasound revealed ascites too in addition to
dilated portal vein.

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Translator

Welcome

I'm Jeevan. Along with Angel, my wife and four energetic kids - 2 daughters, Charis (6 years) and Hesed (4 years) and 2 sons, Shalom (9 yrs) and Arpit (2 years), we live in a remote town in North India.

We serve at a small dispensary attached to a Catholic mission which in addition to the clinic also has a parish and an ICSE school. We serve the most poor, backward and marginalised groups in the surrounding community. I use this blog to share about the people whom we serve and care for and our lives.